Still's Pharmacy, Inc. v. Cuomo

981 F.2d 632, 1992 U.S. App. LEXIS 32073
CourtCourt of Appeals for the Second Circuit
DecidedDecember 4, 1992
DocketNos. 13, 17, Dockets 92-7102L, 92-7104XAP
StatusPublished
Cited by1 cases

This text of 981 F.2d 632 (Still's Pharmacy, Inc. v. Cuomo) is published on Counsel Stack Legal Research, covering Court of Appeals for the Second Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Still's Pharmacy, Inc. v. Cuomo, 981 F.2d 632, 1992 U.S. App. LEXIS 32073 (2d Cir. 1992).

Opinion

MINER, Circuit Judge:

Defendants - appellees - cross - appellants Mario Cuomo, as Governor of the State of New York, and Cesar A. Perales, as Commissioner of New York State’s Department of Social Services (“DSS”), (collectively “the State”) moved in the United States District Court for the Southern District of New York, pursuant to Fed. R.Civ.P. 60(b) and 70, to modify a Stipulation of Settlement and Order (“Settlement Order”) entered into between the State and the plaintiff-appellant-cross-appellee Pharmaceutical Society of the State of New York (“the Society”) and to dissolve an injunction issued by the district court on February 28, 1988 prohibiting the State from deviating from the terms of the Settlement Order. The State desired to change the method of calculating generic prescription drug prices for Medicaid reimbursement and to add a “sunset clause” to the Settlement Order. The Society cross-moved, pursuant to Fed.R.Civ.P. 60(b) and 70, to modify the Settlement Order to increase the dispensing fee for Medicaid drug prescriptions. Following oral argument, an order was entered in the district court (Duffy, J.): changing the method used to calculate generic prescription drug prices in the Settlement Order, dissolving the injunction and denying both the State’s motion to add a sunset clause to the Settlement Order and the Society’s motion to increase the dispensing fee. Judge Duffy subsequently amended his order to grant a post-proceeding application made by the State to change the method of calculating other prescription drug prices not addressed in his first order. Both parties appeal from the district court’s orders. We affirm in part, reverse in part and remand.

BACKGROUND

We assume familiarity with our opinion in Pharmaceutical Soc’y of the State of N.Y., Inc. v. Cuomo, 856 F.2d 497 (2d Cir.1988) (“Pharmaceutical F), affirming the injunction issued by the district court on February 29, 1988, and therefore provide only a brief summary of the facts and circumstances leading to the issuance of the injunction.

In July of 1978, the parties entered into a stipulation regulating the method of calculating prescription drug prices to be paid to pharmacists as health care providers for Medicaid reimbursement in New York. The stipulation was approved by an order of the district court entered on July 7, 1978. Paragraph four of the Settlement Order provides that the State will reimburse pharmacists participating in the Medicaid prescription drug program for all drugs by using the Estimated Acquisition Cost (“EAC”) method. The EAC method was the same method used in 1978 by the Health Care Financing Administration (“HCFA”) of the United States Department of Health and Human Services (“HHS”) to reimburse states for their Medicaid outlays. See 42 C.F.R. §§ 447.331-.332 (1986). The Settlement Order provides that the EAC is to be calculated by using the Average Wholesale Price (“AWP”) paid by pharmacists for the drugs.

Paragraph nine of the Settlement Order provides that the pharmacists will receive a dispensing fee from the State to reimburse them for the cost of processing Medicaid prescriptions. The fee set in the Settlement Order was $2.60 per prescription and has remained unchanged. Paragraph six requires the State to hold an annual hearing at which the pharmacists can seek an increase in the dispensing fee.

Paragraph eight of the Settlement Order provides that the estimates used to calculate the prescription reimbursements shall be updated no less frequently than four times a year and no more frequently than once a month. Paragraph ten provides that the method for determining prescription reimbursement prices may be changed pursuant to the mandate of federal laws and regulations or state law.

On October 29, 1987, new federal regulations promulgated by HCFA took effect. See 42 C.F.R. §§ 447.304, 447.331-.332 (1991). These regulations changed the method used by HCFA to calculate reimbursements to states for generic drugs (referred to in the regulations as “Multiple Source Drugs” or “MSDs”). See id. §§ 447.331(a), 447.332. The new method [635]*635employed by HCFA was called the Aggregate Upper Limit (“AUL”) method. Under the AUL method, HCFA published tables listing the maximum prices it would use in reimbursing a state for various generic drug prescriptions. These prices are referred to in the regulations as Specific Upper Limits (“SULs”).1 Id. § 447.332. To be eligible to receive full federal subsidization of its Medicaid outlays under 42 C.F.R. § 447.304, a state’s total drug prescription expenditures cannot exceed the aggregate of the SULs for each prescription reimbursed plus a reasonable dispensing fee determined by the state. Id. § 447.332(b). Thus, to be eligible for Full Financial Participation (“FFP”) in the federal Medicaid program, a state does not have to pay a pharmacist the SUL for each drug as long as the total amount of money it expends does not exceed the aggregate SULs for all the prescriptions for which it provides reimbursement.

The regulations governing all other prescription drugs (“other drugs”) continued to provide that the AUL be calculated by using the lower of (i) the EAC of the drug2 plus a reasonable dispensing fee established by the state; or (ii) the pharmacist’s usual and customary charge for the drug. Id. § 447.331(b). Thus, the AUL for other drugs is the amount a state would pay if it paid for each drug in this category at the lower of these two figures.

Compliance with the regulations pertaining to generic drugs is not mandatory, and a state may use any method it chooses to reimburse pharmacists for Medicaid drug prescriptions. See Pharmaceutical I, 856 F.2d at 502-03. Failure to comply with the federal reimbursement cap, however, results in a loss of federal funds, which a state would have to replace with money from its own treasury.

In January of 1988, believing that the Settlement Order’s requirement that AWP be used to calculate EAC violated the new federal regulations and placed it in jeopardy of losing its federal Medicaid subsidies, the State unilaterally amended its regulations to adopt the new federal method of calculating generic drug prescription reimbursement, see N.Y.Comp.Codes R. & Regs. tit. 18, § 505.3(h)(2)(v) (1988), without seeking approval from the district court. The new amendment provided for the use of the SULs published by HCFA to reimburse pharmacists for generic drug prescriptions plus a reasonable dispensing fee. Because the State had violated the provisions of the Settlement Order, the Society sought and obtained an injunction from Judge Duffy prohibiting the State from implementing the new regulations.

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Related

Still's Pharmacy, Incorporated v. Cuomo
981 F.2d 632 (Second Circuit, 1992)

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Bluebook (online)
981 F.2d 632, 1992 U.S. App. LEXIS 32073, Counsel Stack Legal Research, https://law.counselstack.com/opinion/stills-pharmacy-inc-v-cuomo-ca2-1992.